The client has an endotracheal tube and is on a mechanical ventilator and the nurse establishes Ineffective airway clearance as the client's nursing diagnosis. Which is the priority nursing in-tervention for the client's nursing diagnosis?
1. Maintain airway patency.
2. Suction endotracheal tube.
3. Maintain SaO2 above 95%.
4. Check breath sounds often.
2
2. The priority nursing intervention for Ineffective airway clearance is to suction the endotracheal tube to remove secretions that can obstruct the airway.
1 and 3. Maintaining airway patency and the oxygen saturation are reasonable goals for the client.
4. Checking breath sounds is a reasonable nursing intervention for both goals, but suctioning the airway is a better intervention to manage an ineffective airway clear-ance because it is a proactive intervention.
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